Synopsis On 16 April 1993, the fully loaded CANADIAN EXPLORER was navigating upbound in the St. Lawrence River under winter navigation conditions. The vessel, which was under the conduct of a pilot, touched bottom on the south side of the channel off Lotbinire, Quebec, in daylight and in fine weather conditions. The Board determined that, while transiting the Richelieu Rapids under the conduct of a pilot, the CANADIAN EXPLORER touched bottom because neither the pilot nor the officer of the watch effectively monitored the vessel's progress in an area of strong current. 1.0 Factual Information 1.1 Particulars of the Vessel CANADIAN EXPLORER Official Number - 323003 Port of Registry - Toronto, Ontario Flag - Canadian Type - Bulk carrier Gross Tons - 16,353 Length - 217.79 m Draught - F2: 7.87 m (at time of occurrence) A: 7.90 m Built - 1965, rebuilt in 1983 Lauzon, Quebec Propulsion - Sulzer five-cylinder, 6,100 BHP Owners - Upper Lakes Shipping Corp. Toronto, Ontario 1.1.1 Description of the Vessel The CANADIAN EXPLORER is a bulk carrier with all aft accommodation. 1 Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System (SI) of units. 2 See Glossary for all abbreviations, acronyms, and definitions. 3 All times are EDT (Coordinated Universal Time (UTC) minus four hours) unless otherwise stated. 1.2 History of the Voyage On 16 April 1993, the CANADIAN EXPLORER was en route from Port Cartier, Quebec, to Hamilton, Ontario, with 23,870 tonnes of iron ore. On board were 22 crew members, including the master. There was a change of pilot at Qubec, Quebec, at 03303. After a cursory exchange of formalities between the pilot and the master, the latter left the bridge for his cabin at about 0350. The bridge was now manned by the officer of the watch (OOW), the helmsman was at the helm, and the pilot had the conduct of the vessel. At about 0640, under orders from the pilot, the vessel's course was altered to 222 Gyro (G) as the vessel entered the Richelieu Rapids (see Appendix A). The vessel was stemming a strong ebb tide. There is conflicting evidence respecting the vessel's speed. The pilot maintained that the vessel's average speed over the ground in the Richelieu Rapids was three to four knots (kn). At about 0647, when the vessel was off Richelieu Island, the pilot ordered the course to be adjusted to 225(G). The helmsman maintained that course for over 15 minutes, until the vessel struck bottom and sheered to starboard. There was no other traffic in the vicinity. The helmsman called out to the pilot, who was seated in front of him, and asked for instructions. As he did not get an immediate response, he resorted to trying to get the pilot's attention physically by shaking him. The pilot then stood up, looked out of the window, and ordered the helmsman to steer in the middle of the river. The OOW immediately summoned the master and plotted the vessel's position. The time of bottom contact was 0707, and the position was recorded as 4637'15N,07157'W. The master arrived on the bridge and, upon asking the pilot, was advised that the pilot had fallen asleep. This communication was overheard by the helmsman. There was no further communication between the pilot and the master. The master remained on the bridge until the pilots changed at Trois-Rivires, Quebec. The CANADIAN EXPLORER reported the occurrence to the Quebec Vessel Traffic Centre (VTC) at 0720 and continued on her passage. The vessel arrived at Hamilton at 1652 on 18 April 1993 without further incident. The forepeak and the forward holds were sounded, and no ingress of water was found. A subsequent survey noted some distortion of the shell plating at the bilge radius and of the floors in the No. 1 port ballast tank. There was no injury. 1.3 Vessel Certification The CANADIAN EXPLORER was certificated, equipped, and manned in accordance with existing regulations. 1.3.1 Personnel Certification The crew members of the CANADIAN EXPLORER who were directly involved in this occurrence held the appropriate certification, and the pilot was appropriately licensed. 1.4 Personnel History The master had 20 years' experience as an officer. He had 14 years' experience as a master and had been on the CANADIAN EXPLORER since 1988. The first mate, who was the OOW, had 13 years' experience as an officer. He joined the company in July 1989 and the CANADIAN EXPLORER in March 1993. The helmsman had 20 years' experience as a deck-hand. His tenure as a helmsman was with this company. He had joined the CANADIAN EXPLORER in March 1993. The pilot had 16 years' experience piloting vessels in District No. 2, Qubec/ Trois-Rivires. The last 11 of these years were as a Class A pilot. He was familiar with the CANADIAN EXPLORER, having piloted the vessel several times in the past. 1.5 Weather Information The weather forecast for the area was consistent with that experienced by the vessel. Weather conditions included a north-easterly wind at 10 kn and visibility of over 10 miles. The time of sunrise, as calculated, was 0600. 1.5.1 Current and Tidal Information On 16 April 1993, high tide at Barre Boulard, Quebec, was at 0354; low tide was at 1120. At the time of the occurrence, the tide was ebbing. The ebb current as depicted on Canadian Hydrographic Service chart No. 1334 for the Richelieu Rapids and Barre Boulard runs parallel to the channel. It runs in the direction 042 at 5.6 kn for the Richelieu Rapids and in the direction 054 at 5.6 kn for Barre Boulard. The ebb current at the Richelieu Rapids can reach a maximum of 8 kn under certain conditions (Sailing Directions, St. Lawrence River, Cap-Rouge to Montral). 1.5.2 Water Level The depths on charts are referenced to a lower water level, called chart datum, so that the water surface will seldom fall below the given figures. The water level recorded at the gauge at the Portneuf, Quebec, wharf, which is some three miles downstream from Lotbinire, was as follows: The depth at the position where the CANADIAN EXPLORER touched bottom was, therefore, more than the charted depth (see Appendix A). 1.6 Navigation Equipment 1.6.1 Vessel Equipment The vessel's navigation equipment included two radars, a Loran C, a gyrocompass, a magnetic compass, and an echo-sounder. Only the compasses and one radar were in use at the time of the occurrence; the second radar was on stand-by. The navigation equipment and machinery in use were functioning satisfactorily. 1.6.2 Fixed and Floating Navigational Aids From Cap-Rouge to Trois-Rivires, the shoreline is quite low and lightly wooded. The main ship channel, which has a least depth of 10.7 m and a least width of 244 m, is marked by buoys and leading lights (ranges). The lighted buoys in the Richelieu Rapids and Barre Boulard channels had been lifted and replaced by spar buoys for the winter. The fixed navigation aids in the area were reported to be operating normally at the time of the occurrence. The Lotbinire leading lights are situated some 2.5 miles above Richelieu Island. These lights, in line bearing 222, lead through the Richelieu Rapids and are visible in line of range only. The Barre Boulard leading lights are situated on the south-east shore south of Portneuf. These lights, in line with the Richelieu Island light bearing 054, lead through the Barre Boulard dredged channel and are visible in line of range only. These lights are astern for an upbound vessel, but there is good visibility astern from the wings of the bridge on the CANADIAN EXPLORER. The alter-course position from 222 to 234 is off buoy Q73. 1.7 Conduct of Navigation The hand-over procedure between the relieved pilot and the relieving pilot was described as very informal. There was no communication between the OOW and the pilot respecting the navigation of the vessel, nor was there a formalized relationship between them. The last communication between them took place at 0635, when the vessel was abeam of Portneuf. This conversation concerned the ice trapped behind the wharf. The pilot, who had the conduct of the vessel, gave steering orders directly to the helmsman. Reportedly, he checked the vessel's position by radar, but he could not recollect how frequently he did so. He further indicated that the high water and strong current had submerged the spar buoys and that the current in the area was three to four times the normal rate. He estimated that the vessel had been on the last course of 225(G) for about 15 to 20 minutes and alleged that the strong current had pushed the vessel out of the channel in a matter of seconds. The OOW used the radar and referred to the chart to monitor the progress of the vessel and make appropriate entries in the log. He was unable to confirm or deny if any of the spar buoys were under water, but he did see some of them during the passage from Qubec. At the time of the bottom contact, the OOW was walking from the chart table to the starboard radar and was unable to tell if the pilot was awake or asleep. During the watch, the helmsman was periodically relieved briefly by the OOW so that he could make coffee. The helm orders from the pilot were first repeated by the helmsman and then executed. Once executed, they were reported again to the pilot. Before bottom contact occurred, the last course ordered by the pilot and executed by the helmsman was 225(G). 1.7.1 Navigation with Pilot Embarked Acknowledging the need for training requirements and reinforcement of the basic principles relating to the keeping of a navigational watch, the Canadian Coast Guard (CCG) published the Recommended Code of Nautical Procedures and Practices, in keeping with the IMO's International Conventional on Standards of Training, Certification and Watchkeeping for Seafarers, 1978. The Code states that: Despite the duties and obligations of a pilot, his presence on board does not relieve the master or officer in charge of the watch from their duties and obligations for the safety of the ship .... The master and the officer of the watch shall co-operate closely with the pilot and maintain an accurate check of the ship's position and movement. The owners' Manual of Standard Procedures also points out that the presence of a pilot does not relieve the master (or deck officer) of the responsibility for the safe navigation of the vessel. The manual states the need for the OOW to monitor the vessel's position and to assist and advise the pilot. In this instance, the OOW did not effectively monitor the vessel's position but rather relied implicitly on the pilot. 1.7.2 Position Discrepancy The position of bottom contact as reported by the pilot to the VTC was the same as that recorded in the ship's logbook. However, during the investigation, the pilot maintained that the position was further north. 1.8 Rest and Work Schedule The OOW worked a four-hours-on/ eight-hours-off watch system. His watch period was 0400-0800 and 1600-2000. On 15 April 1993, he went to bed at 2230 and was called for his watch at 0330. He felt rested and fit for his duties. The helmsman worked the same watch system as the OOW and was reportedly rested. The pilot's schedule called for 12 days of work followed by 12 days off work, no more than one assignment a day, and a minimum of 14 hours off duty between assignments. He maintained two residences, one in Qubec and the other in Trois-Rivires. The pilot reported that he does not drink or smoke and that he did not take any drugs prior to this assignment. He further indicated that this was his third consecutive night assignment and that he was tired. According to the work schedule provided by the Laurentian Pilotage Authority (LPA), the pilot had performed the following pilotage assignments: SAUNIRE 10 April 1993 0015 to 1358 ENERCHEM CATALYST12 April 19932310 to 1325 CANADIAN EXPLORER 16 April 19930320 to 1115 1.9 Irregular Work Schedule and Human Performance Extensive research has been conducted on the subject of the impact of shift work and irregular work patterns on human performance. Physiological activity varies throughout the day according to circadian rhythms. Working during periods when people normally sleep has certain predictable consequences. Alertness decreases and reaches a low point in the early morning hours. This decreased alertness, coupled with a shortage of sleep, predisposes an individual to inattention, a breakdown in the ability to monitor situations or instruments, and drowsiness to the point of falling asleep. The effect can be cumulative with repetition and can be more pronounced when night work is combined with irregular schedules, which make adjustment even more difficult. People can become susceptible to micro-naps lasting from seconds to a few minutes without their awareness. In this instance, the pilot drove his car from Qubec to Trois-Rivires on 15 April 1993. He went to bed at about 2230 and slept well until 0020, 16 April 1993, when he received a telephone call for an assignment in Qubec. He spent two hours travelling to Qubec by taxi. The pilot could not recall having admitted to the master that he had fallen asleep, but he emphasized that he was tired. He spoke a lot about fatigue and stated that he was unable to sleep during the day after working through the night. 1.10 Training and Safety The negative effects of shift work and irregular work schedules can, however, be mitigated by a combination of sleep schedules and control of one's environment and diet. Training and educational programs to help these workers maintain optimum performance despite irregular work/rest schedules have been developed and can be customized to meet specific needs. The pilot was aware of material available on work-related stress, fatigue and performance maximization for people with irregular work schedules. However, the LPA has neither a directive nor an educational program in place to provide guidance for pilots. 1.11 The Role of the Pilot In Canada, the Pilotage Act requires that, in a compulsory pilotage area, a licensed pilot or holder of a pilotage certificate have the conduct of the vessel subject to compulsory pilotage. The pilot is responsible to the master for the safe navigation of the vessel, and he is retained to direct the navigation of the vessel.